Time Factors
Medicaid Pre-D Standard - decision is due in what time frame based on the receipt of the request
a) 24 hours
b) 48 hours
c) 2 business days
What is two business days
When do you need a primary denial prior to being able to conduct a review
When UPMC is secondary coverage
Needs to be completed to gather additional information about patient needs on initial patient contact or every 6 months
What is a PHR - Patient Health Review
A cardinal rule for nursing documentation is
What is "If it wasn't documented, it wasn't done"
or "every note should tell the story"
The RN will process an Administrative Denial for an 18 year old when something is requested that is not a covered item. True or False?
What is "False".
Under the age of 21 the request must be reviewed for medical necessity
How many attempts must be made to Medicaid members for denials
What is "One"
When a procedure code requires a prior auth for a Medicare case, documentation of a ___ is required
What is an LCD/NCD
Needs to be deactivated prior to closing a case management case
What is PGI - Problems, Goals and Interventions
How many outreach attempts must be made to obtain additional information
What is "3"
The determination that is used when services or items are partially approved and partially denied
What is MA Partial Approval
Medicare - The amount of time given for a decision on an expedited request
a) 3 Days
b) 72 hours
What is 72 hours
A DME case is pended for further information, when is a decision required
What is 14 days
How man call attempts should be made before close a case management case
What is 2 call attempts on 2 different days at different times of day
It is day 14 and the decision has just been made, what must you do to notify the member?
What is "an outreach call"
To be a true readmission - all 6 Criteria must be met
True of False
What is "True"
Medicaid Expedited Request -request for additional information must be done within ______ number of hours
What is 24 hours
MC/SNP - RN is able to do this for MC/SNP if the request is not a covered benefit
What is make the decision for Administrative Denial
When should you refer a case to case management?
a)when you are completing a UM case
b)when you notice a patient will have discharge needs
c)when you notice that they have a chronic illness
d) all of the above
What is "all of the above"
Who can make a request on behalf of the member?
What is "the provider, member or member's representative"
Letters - For Medicaid Denials - who will review and generate that letter?
What is "Will be send to CO Letter Review"
Medicare Acute - How much time is allowed for a decisions when additional information is requested
What is "within one business day after requesting the additional information"
Recurrent reauthorization cases need to be closed how often?
What is annually
Referrals from stratification should be called within 30 days. When should all other cases be contacted?
As soon as possible and no later than......
What is Two Business Days
The timeframe of when a case begins if an AOR is requested?
What is when the AOR is recieved
72 hours for Expedited
14 Calendar days for Standard
Responsible for automatically generating the Approval Letter for Medicaid LOB
What is UPMC